What s New in Fingertip Injuries. Gordon A. Brody, MD SOAR Redwood City

Transcription

1 What s New in Fingertip Injuries Gordon A. Brody, MD SOAR Redwood City

2 Goals of Treatment Durable Sensate Aesthetic Preserve Length Preserve Mobility

3 Goals of Treatment Pain and Worker s Compensation are the most important factors in determining RTW after finger injuries Significant predictors of DASH Job burnout/satisfaction less important J Hand Surg 2012;37A:

4 Assessment Angle of Loss Percentage nail preserved <50% leads to hook nail deformity-ablate Bone exposed? Size of defect?

5 Treatment Open Wound Management No bone exposed Wounds <1cm Simple, best in children Sensate, similar skin Reduced padding, tender stump 3-6 weeks to heal

6 Treatment Composite Graft Age <2years Biologic dressing in adult Undpredictable

7 Treatment Skeletal Shortening, Revision Amputation Never shorten thumb Quick recovery Proximal to lunula should ablate nail Laborers, heavy contamination

8 Treatment Skin Graft Preserved padding present Wound >1cm

9 Local Flaps V-Y Flap Transverse/Palmar Oblique Distal transverse defects >50% nail preserved Durable, sensate Up to 10 mm. distal edge advancement Volar V-Y better than lateral Kutler

10 J Hand Surg 2012;37A: Local Flaps

11 Pivot Flap

12 Pivot Flap Excellent sensory recovery at 2 mos. Mild cold intolerance No painful tips

13 J Hand Surg 2011;36A: Local Flaps

14 Step-Advancement Flap

15 Step-Advancement Flap

16 Step-Advancement Flap No need to shorten bone Near normal ROM Static 2-pt is 3 to 5 mm No donor site morbidity

17 J Hand Surg 2013;38A: Local Flaps

18 IDAP Flap

19 IDAP Flap Larger defects than V-Y 3.5 x 2 cm Excellent sensation (close to opposite hand) No joint contractures

20 Moberg Flap Thumb only Dorsal skin has independent blood supply IP contracture for defects >1.5 cm

21 Heterodigital Flaps Cross Finger Large wounds, exposed bone Release Cleland s ligament Thenar Flap Index/Middle only Best <40 yo RDN at risk

22 FDMA Flap Ideal for thumb coverage 1 st. Dorsal MC Artery is branch of radial artery 2 pt. 11 mm Requires cortical reorientation Good donor site

23 Question The arterial supply of the flap shown in Figures 1 and 2 is: A. First dorsal metacarpal artery B. Dorsal antebrachial superficialis artery C. Second common digital artery D. Deep to the aponeurosis E. Supplying terminal skin on the dorsum of the index finger at the level of the middle phalanx

24 Question Preferred Response: A Discussion: This patient underwent treatment with a kite flap. The first dorsal metacarpal artery provides the blood supply for this flap. It is a very predictable and constant artery that arises from the radial artery. Foucher and Braun noted only 2 of 30 dissections demonstrated that it arose from the dorsal superficial antebrachial artery. It lies primarily on the dorsal radial side of the index finger. Its terminal skin supply is the dorsal aspect of the proximal phalanx of the index finger. While some aponeurotic fibers may cross over the artery, it lies on (superficial to) the aponeurosis. References Foucher G,Braun JB. Anewislandflaptransferfromthe dorsum of the index to the thumb. Plast Reconstr Surg 1979;63: Shi SM, Lu YP. Island skin flap with neurovascular pedicle from the dorsum of the index finger for reconstruction of the thumb. Microsurgery 1994;15:145-8.

25 Question The palmar neurovascular advancement flap (Moberg) is most appropriate for reconstruction of which of the following defects? A)Thumb pulp B)Index finger pulp C)Thumb nailbed D)Thumb dorsum E)Index dorsal middle phalanx

26 Question Preferred response: A Discussion: Use of the Moberg flap requires an independent dorsal blood supply for digit viability as seen in the thumb but not predictably in the fingers. The Moberg flap therefore is best used for volar pulp defects in the thumb of up to 1 cm (see Figures 1, 2, and 3). Additional advancement can be achieved by exposing and mobilizing the neurovascular structures. Flexion contractures, a frequent outcome of this mobilization, are better tolerated in the thumb than in the fingers. Index finger pulp loss can be treated with the cross-finger flap. A flap from the first dorsal metacarpal artery can be used to cover dorsal thumb defects, and defects over the index dorsal middle phalanx can be covered using skin grafts or with the extended dorsal metacarpal artery flaps. The Moberg flap does not have sufficient length to cover nailbed defects. References: BaumeisterS,MenkeH,WittemannM,GermannG.Functional outcome after the Moberg advancement flap in the thumb. J Hand Surg 2002;27(1): Friedrich JB, Katolik LI, Vedder NB. Soft tissue reconstruction of the hand. J Hand Surg 2009;34(6):

27 Thank you!